Scott Benjamin, DDS

The dental profession has always relied on technological advances to move forward, integrate the newest ideas, expand, and keep dentistry up-to-date. The more resources available—and the more innovative they are—the greater the chance that patients can receive enhanced care. Digital radiography is one area of dental technology that provides multiple capabilities and opportunities to treat patients more effectively, safely, and efficiently. Its integration into practice, however, requires consideration as part of an overall technology plan for maximum productivity, return on investment, and information interoperability.

Unfortunately, some practices avoid implementing new technology for reason such as: cost; inability and/or unwillingness of staff to learn new systems; software and hardware issues; and the notion that digital radiography is simply unnecessary. However, digital radiography is fast becoming not just the future, but the current standard of care in dental practice and a requisite to conform to new regulations.

Standards Affecting Digital Dental Radiography

Generally, the implementation of digital dental radiography is not undertaken without questions, opinions, and concerns. One concern is the risk of radiation. Evidence from the National Council on Radiation Protection’s Report No. 145 demonstrates that dentistry has been adhering to the as low as reasonably achievable (ALARA) principle regarding radiation.¹ A switch to digital radiography, which uses less radiation than traditional radiography, is in keeping with this philosophy. The report outlines several guidelines for both traditional and digital radiography to ensure that dentists are aligning themselves with the ALARA principle. According to those guidelines, practitioners using traditional panoramic radiography must use high-speed, rare earth screen–film systems, or a digital system of equal or greater speed; and those using traditional or digital cephalometric forms of radiography must use the fastest screen-film systems compatible with imaging requirements. Practitioners should also collimate the beam to the area of clinical interest to reduce the possibility of overexposure to radiation.²

Other standards also apply. According to Gregory Zeller, DDS, MS, Senior Director for the American Dental Association (ADA) Research and Laboratories, Center for Medicare and Medicaid Services (CMS), meaningful use (MU) incentive payments, are available for dentists—primarily those who are Medicaid providers—who demonstrate MU with an Office of the National Coordinator-Certified Electronic Health Record (EHR); current ONC certification criteria are based on standards from the foundation for other future EHR certification standards that will be more applicable to the general patient population.

“Advanced imaging accreditation requirements are mandated by CMS for reimbursement of Medicare providers and have subsequently been legislated for all providers in California and Minnesota. Third-party payers may also require this accreditation for reimbursement under dental benefit plans,” Zeller explains. “For dentistry, this accreditation requirement applies to cone-beam computed tomography (CBCT) systems. The Intersocietal Accreditation Commission (IAC) offers accreditation of dental CBCT imaging systems.”

Secure and private electronic transmission of patient data over the Internet is another prominent regulatory issue and is covered by Health Insurance Portability and Accountability Act (HIPAA) requirements, Zeller adds. Dentists must comply with the HIPAA regulations that are currently in place. Accreditation for dental CBCT systems, as advanced imaging systems, is in its initial stages of implementation and is expected to continue to grow. Dentists, as leaders of the patient-centered oral healthcare team, will need to use dental EHRs that can exchange data with medical EHRs. Whether the dental EHR is a stand-alone product installed in the dental office or is integrated as a module of a medical EHR, all medical information—including clinical findings, images, and treatment rendered—must be shared among providers to achieve the goal of improving the overall coordination of healthcare for patients.

To facilitate this objective, the ADA advocates the Digital Imaging and Communications in Medicine (DICOM) standards. Because DICOM images contain information about the patient, procedures, and whether the images have been altered or enhanced in any way, they are nearly useless unless they can be shared with those who need it, when they need it.

“Digital Imaging and Communications in Medicine (DICOM) standards offer interoperability that will assure persistent display of images among various digital imaging systems so diagnostic information will be consistently available,” Zeller says. “For example, when a digital radiographic image is sent by a general dentist to an endodontist, the endodontist will see the same high-quality image that the referring dentist viewed.”

The ADA has partnered with Integrating the Healthcare Enterprise (IHE). According to Zeller, IHE uses “base” standards, such as DICOM and Health Level Seven (HL7), and develops implementation standards, called Integration Profiles, which are then tested for interoperability among vendors at refereed events called Connectathons.³ If the implementation standards are successful, additional demonstrations of interoperability among vendors using products on the market is another way to demonstrate how valuable these products are in the “real world.” IHE and the ADA are collaborating on dental imaging vendor participation in the January 2014 IHE Connectathon, with an interoperability demonstration to follow at the 2014 ADA Annual Session.

Additionally, ONC Health Information Exchanges (HIEs) are designed to offer a method for sharing information among providers and institutions, such as hospitals and healthcare delivery systems with geographically dispersed locations, Zeller notes. HIEs use the National Health Information Infrastructure (NHII) and National Health Information Network (NHIN) approaches to achieve this information exchange. HIEs are currently under development and implementation with initial federal funding incentives from ONC; however, the ultimate goal for HIEs is that they be financially sustainable without federal funding, Zeller says.

According to Veeratrishul Allareddy, BDS, MS, associate professor at the University of Iowa, the College of Dentistry, and co-chair of DICOM Working Group 22, many dentists aren’t aware of organizations like DICOM, HL7, or IHE. This is why recommendations from the ADA regarding broad outlines of the common mandates make it easier for dentists to understand what’s required: that information be digital and capable of being communicated in a compliant (compatible) way.

Developing the Overall Technology Plan

Since going digital will be crucial to dentistry in the future, developing a well-thought-out technology plan for the practice will be essential, both for initial changes and long-term endeavors. With a plan in place, integrating digital radiography can be an initiative to expand the practice and provide the best and most efficient treatment possible for patients, as well as comply with current and future healthcare policy mandates.

To start, Allareddy recommends that dentists acknowledge that change is a slow process. Transferring records from a previous system into a new one—whether paper charts to digital records, or digital imaging from one patient management system to another—can be complex. There are likely to be challenges along the way. However, once everything is in place, it will be well worth it, he advises.

Then, it’s important to assess the current information technology (IT) infrastructure in the practice by examining the systems that are currently integrated, and determining the equipment/software that must be updated and what needs to be added. This sets the stage for investigating and ultimately incorporating the most appropriate digital, diagnostic, clinical, and IT equipment.

According to Jeffery Price, DDS, MS, an oral maxillofacial radiologist and associate professor of oral maxillofacial radiology at the University of Maryland School of Dentistry, the very first thing dentists should do is take an inventory of their practice to determine what kind of practice it is (eg, high or low volume; general family dentistry or restorative; TMD cases). This will help dentists determine what their most common diagnostic question is and, therefore, the type of radiography scenario they’ll be faced with most often, he says.

“The most commonly used information technology infrastructure in the dental office today is client-server architecture,” Zeller explains. “Client-server infrastructure is still the best available overall option; however, in the near future, cloud-based computing may offer the full functionality required for dental EHRs.”

Allareddy says there are currently many different systems available (eg, patient management, imaging). When making their technology plans, dentists should ensure that the technology choices they make will be “freestanding” but capable of communicating with systems from different manufacturers (ie, DICOM compliant).

“Dentists want to ensure that the patient management system can ‘talk to’ their digital radiography or imaging system, regardless of the manufacturer,” Allareddy explains. “They can do whatever customization they want to the systems, but if they follow the basic DICOM guidelines, their information can be easily migrated to a different system in the future.”

Digital imaging systems that could be considered to be part of a practice’s technology plan include extraoral, panoramic, cephalometric, CBCT, CAD/ CAM, and visible light imaging systems. All of these imaging modalities are crucial to the overall dental EHR, Zeller confirms. “Imaging is a critical part of dental diagnosis, treatment, and the documentation in the healthcare record,” Zeller says. “Sharing image files securely through interoperability standards will allow better healthcare coordination among the dental team, as well as the overall healthcare team.”

CBCT could be invaluable to a dental practice, providing instantaneous and accurate 3D digital radiographic images for immediate use in patient consultations. Combining an image from several scans offers a clearer overall picture, while collimation of the CBCT beam limits the amount of radiation exposure.

Because CAD/CAM systems have become much easier to use, these also could be considered part of a digital technology plan. Using digital radiography with in-office CAD/CAM could provide the convenience of impression scanning and the ability to direct-mill restorations and surgical guides during a patient’s appointment. This could reduce costs by eliminating laboratory and other material fees while enhancing patient care and efficiency.

Another important consideration is acknowledging that technology can become quickly outdated, thereby warranting research into new systems, materials, and the companies that manufacture and/or market them prior to purchase. Hardware or software may require frequent updates, so anticipating a potentially frustrating reconfiguration to an office or space—and the vendor support necessary to make it a stress-free process—is part of a careful planning process.

Additionally, testing systems before purchase within the practice itself can help to determine if they will work within the practice on a day-to-day basis. Some newer digital dental radiography systems may be too difficult to use or, after careful planning, may not offer the return on investment originally hoped for.

In developing the technology plan, soliciting staff input in the decision-making process can help ensure their ability to maintain smooth operations. If they have concerns or questions, these should be addressed prior to implementing the technology plan and investing in specific technology systems. Also to be considered are the needs and expectations of patients when integrating new technology and formulating the digital IT plan.

Conclusion

“The ultimate goal [of digital radiography and a practice technology plan] is the ability to share patient EHR data anywhere and any time on a wide variety of devices, including mobile devices,” Zeller concludes. “Dental offices should use digital systems that implement standards-based information-exchange criteria to allow interoperability among internal dental office systems and to offer the capability of sharing digital information with external entities for treatment, payment, and healthcare operations.”

Disclosure

Dr. Benjamin is a consultant for Sirona.

Reasons for Making the Change

It’s important for practices to stay current, but new technology should serve a purpose. The goals of all technologies are to enhance the quality of care clinicians provide for their patients and increase the efficiency in how quality care is delivered. Therefore, to begin planning, evaluate the types of care the practice provides, what its imaging and diagnostic needs are, and what is needed to enhance care, efficiency, and productivity. Consider asking the following questions:

• Is the technology expected to fix, enhance, or change the way things are currently being done?

• Where are the bottlenecks and inefficiencies in the practice workflow?

• Which piece of technology will help resolve problems?

• Where does the practice want to be today, tomorrow, and in a few years?

What Is Needed, Not Just Desired

Digital radiography systems can be expensive in terms of time, money, and space requirements. It’s important for dental professionals to honestly assess what they really need and if it fits into many aspects of their practice—both current and future. Assessing the practice honestly in terms of its strengths and weaknesses is therefore important in determining what’s needed versus what’s wanted.

• Is the staff strong on insurance management?

• Is the staff technologically and computer savvy?

• What is the physical space required to incorporate and support the technology?

• What constraints to integrating digital radiography or other technologies exist in the practice?

Information to Gather

Systems and technology being considered should be carefully researched. It is helpful to consult with colleagues, check with professional publications, and otherwise take steps to cultivate background knowledge of what will certainly be an important addition to the practice. Such research should evaluate the following:

• Does the hardware/software vendor have expertise and stability in the areas needed?

• Can images be acquired, saved, and transferred properly (ie, DICOM compliant)?

• Is the necessary space available to integrate the technologies desired?

• Will existing technology support the additions and changes being contemplated or will upgrades be required?

• Is the new system compatible with other systems in the office?

Make Sure Training Is Included

The company from which products are being purchased must be able to provide the training required with all digital imaging technologies. Even more importantly, the practice must plan for and allocate the time to train all team members to an appropriate level of competency. This is the time to ask questions and learn as much as possible about the subtleties of the system and technology. It is important to ensure that follow-up support is available if new questions or concerns arise. In addition, follow-up training within the first year of purchase should be arranged to make sure everyone is still on track and maximizing the investment.